MEDICARE: NATHAN ALEXANDER BONILLA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer
2	390200000X	Student in an Organized Health Care Education/Training Program		FL

General Provider Information

NPI Number	:	1821842972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHAN ALEXANDER BONILLA

Provider Business Mailing Address
First Line	:	2720 RIVER RIDGE DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32825-8768
Country	:	US
Telephone Number	:	407-451-2708
Fax Number	:

Provider Business Practice Location Address
First Line	:	2720 RIVER RIDGE DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32825-8768
Country	:	US
Telephone Number	:	407-451-2708
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2024
Last Update Date	:	04/15/2024

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